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Exercise is Medicine®: A Global Health Initiative

Dietitians with the passion to work with this challenging segment of the population will be a much-needed resource in the dietetics community in the years to come. These are the basic concepts of health which have been obscured by the pharmaceutical drug establishment. Webinars are also available on their YouTube channel. In return, the owners of the genetic resources would get a share of the benefits arising from their use and development in the way of information, technology transfer and capacity building. Release of Genetically Modified Organisms in the Environment: However, abandonment of farming activities can also endanger the environmental heritage through loss of semi-natural habitats as well as biodiversity and landscape associated with them.

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Without prejudice to other Community legislation, the Member States immediately notify the Commission under the rapid alert system of:. To assist the members of the network, information is classified under two different headings, Alert Notification and Informational Notifications. Alert Notifications-Alert notifications are sent when the food or feed presenting the risk is on the market and when immediate action is required. The notification aims at giving all the members of the network the information to verify whether the concerned product is on their market, so that they also can take the necessary measures.

Consumers can be reassured that products subject to an alert notification have been withdrawn or are in the process of being withdrawn from the market.

The Member States have their own mechanisms to carry out such actions, including the provision of detailed information through the media if necessary. Informational Notifications-Informational notifications concern a food or feed for which a risk has been identified, but for which the other members of the network do not have to take immediate action, because the product has not reached their market.

These notifications mostly concern food and feed consignments that have been tested and rejected at the external borders of the EU. Consumers can be reassured that products subject to an information notification have not reached the market or that all necessary measures have already been taken. The Commission publishes a weekly overview of alert and information notifications. As it is necessary to strike the balance between openness and the protection of commercial information, the trade names and the identity of individual companies are not published.

This is not detrimental to consumer protection, as a RASFF notification implies that measures have been or are in the process of being taken. WHO is the implementing agency for the contributing institutions located in over 70 countries around the world.

GEMS' purpose is to compile data on food contamination and human exposure from different countries for global synthesis, evaluation, and presentation. In , GEMS began developing a new data structure and protocols for the electronic data submission. The protocols involve encoding and formatting data in a manner compatible with the database maintained at WHO headquarters.

Protocols for aggregate and individual data on contaminant levels in specific food commodities include descriptions of the data fields needed to ensure complete, quality electronic data submissions. Uniform implementation and wide accessibility of the GEMS system make it a model for expanded, international food surveillance efforts. While there are no all-encompassing international surveillance systems, examples that serve to illustrate the value of such systems have been illustrated.

The structure, function, and interactions between each country's government agencies form the start of an eventually global surveillance, regulatory, and protective framework to curtail the transmission of food-borne diseases. Ultimately, WHO, as the lead international public health organization, could be the focal point of such a global surveillance framework. WHO and FAO, through their collective food safety capability, including the WHO Food Safety Department and the FAO Food Standards Programme, could, with the provision of adequate financial and staffing resources, provide the organizational and scientific capability to support a global food-borne disease surveillance system.

The Forum may wish to consider the following points regarding international cooperation on food contamination and food-borne disease surveillance.

Are there other major programmes and international activities that should be brought forward? Are elements missing from these strategies? What strategies should be pursued to better enable international cooperation on food-borne disease surveillance? How best can their role be enhanced in this area? Farming and nature exercise a profound influence over each other. Farming has contributed over the centuries to creating and maintaining a variety of valuable semi-natural habitats.

They shaped an important part of landscapes worldwide and are home to many of the world's richest wildlife. Farming also supports a diverse rural community that is not only a fundamental asset of international culture, but also plays an essential role in maintaining the environment in a healthy state. Farming is an activity whose significance goes beyond simple food production. Throughout the production chain processes occur that can have an impact on the natural environment and consequently, directly or indirectly, on human health and development.

For example, heavy use of pesticides and fertilizers, incorrect drainage or irrigation practices, a high level of mechanization or unsuitable land use can produce environmental degradation.

However, abandonment of farming activities can also endanger the environmental heritage through loss of semi-natural habitats as well as biodiversity and landscape associated with them. Likewise, the effect of agricultural production systems on human health directly farmer's occupational health or indirectly consumer's health through food are increasingly being recognized as an integrated element in the broader evaluation of environmental risks related to agriculture.

The links between the richness of the natural environment and farming practices are complex. While many valuable habitats are maintained by extensive farming, and a wide range of wild species rely on this for their survival, agricultural loss of wildlife can be the result of inappropriate agricultural practices and land use.

Discussions on possible future environmental effects of new technologies in food production will necessarily have to take outset in the present situation of agricultural effects on the environment, including derived effects on human health, recognizing that present trends of conventional agriculture are likely to be reflected in the objectives of modern food production.

Agriculture adds to greenhouse gas GHG problems. There are three main sources of GHG emissions from agriculture: N2O nitrous oxide emissions from soils, mainly due to nitrogen fertilization; CH4 methane emissions from intestinal fermentation, CH4 and N2O emissions from manure management. Measures being considered include: Further development of renewable, agricultural biomass could contribute to reductions in emissions from energy and transport, while benefiting the agricultural sector.

Water pollution by nitrates from agricultural sources, where improved agricultural practices are thought to improve pollution. Pesticides have been proven to have an effect on the environment and ecosystems by reducing biodiversity, especially by reducing weeds and insects which are often important elements of the food chain e.

In addition, human health can be negatively affected through direct exposure and indirect exposure, e. Systems to reduce the need for pesticide use, especially integrated pest management, organic farming or in some cases genetically modified crops are increasingly investigated at national and international level [22].

Soil degradation processes such as desertification, erosion, decline in soil organic matter, soil contamination e. Such degradation processes can result from inappropriate farming practices such as unbalanced fertilization, over abstraction of groundwater for irrigation, improper use of pesticides, use of heavy machinery, or overgrazing. Measures to prevent soil degradation include support to organic farming, conservation tillage, the protection and maintenance of terraces, safer pesticide use, integrated crop management, management of low-intensity pasture systems, lowering stock density and the use of certified compost.

Irrigation can also lead to environmental concerns, such as over-extraction of water from subterranean aquifers, irrigation driven erosion, soil salinization, alteration of pre-existing semi-natural habitats and, secondary impacts arising from the intensification of the agricultural production permitted by irrigation.

In recent decades, the rate of decline and even disappearance of species and related habitats, ecosystems and genes i. Declines in biodiversity are of direct consequence for food security when they affect food related organisms and relatives with relevance for breeding. Furthermore, intensified agriculture including modern breeding systems has resulted in significant reductions of landraces, adapted to local specificities as well as traditional knowledge.

Assessment of agricultural impacts on the environment requires the use of holistic models which are able to integrate multiple sources of information [23]. Previous scientific discussions have concluded that solutions applied at farm level contributed environmental problems but they are not adequate to the task of realizing long-term environmental goals.

This requires system innovations at higher levels of aggregation, involving, for example, looking for opportunities to negotiate recycling systems by linking sectors within agriculture and other areas affecting the environment, e. As a consequence of public discussion, new concepts for policies of agriculture and environment interactions have been developed in many countries including an improved public monitoring and responsibility for sustainability. Secretary-General Kofi Annan in June , is an international work programme designed to meet the needs of decision makers and the public for scientific information concerning the consequences of ecosystem change for human well-being and options for responding to those changes.

The MA focuses on ecosystem services the benefits people obtain from ecosystems , how changes in ecosystem services have affected human well-being, how ecosystem changes may affect people in future decades, and response options that might be adopted at local, national, or global scales to improve ecosystem management and thereby contribute to human well-being and poverty alleviation. Work on agro-environmental indicators provided information on the current state and changes in the conditions of the environment in agriculture.

It also resulted in a better understanding of linkages between the causes and impacts of agriculture on the environment, looking at agricultural policy reform, trade liberalization and environmental measures.

This all contributes to monitoring and evaluating the effectiveness of policies addressing agri-environmental concerns. Hazards can take many forms, wholly natural in origin or derived from human activities and interventions. In the Convention on Biological Diversity CBD, ratified by countries defined a legally binding instrument for biodiversity protection and sustainable use of biological resources.

The goal of the Convention on Biological Diversity is "the conservation of biological diversity, the sustainable use of its components and the fair and equitable sharing of the benefit arising out of the utilization of genetic resources.

Biological diversity is closely linked to human interests. Biodiversity is highly important for several quite different reasons: It provides a source of significant economic, aesthetic and cultural benefits.

The well-being and prosperity of earth's ecological balance as well as human society depend directly on the extent and status of biological diversity. Naturalism and nature protection: Some difficulties for environmental protection derive from different interpretations and understanding of the idea of nature. Especially in the consumer's debate on the creation of genetically modified organisms, the idea of the need to protect nature was often not well defined, mainly because of differences in the understanding of the concept of nature, ranging between concepts of wilderness, human environment, flexibility of natural systems [34] and ideas of naturalism.

Levels of protection may vary as goals range from sustaining ecosystem services to fully preserving endangered species or fragile protected areas. Biotic homogenization that decreases regional biotas and functional diversity would reduce resilience by reducing the available range of species-specific responses to such environmental changes as droughts, contaminants, or invasive species.

The links between environmental protection and human health through the control of direct and indirect health effects of environmental deterioration needs to be factored into these equations, notably with food safety as one of the direct indicators. Following adoption of hybrid breeding technologies further breeding objectives included methods for the introduction of increased genetic variability using several methods for mutagenesis such as chemical mutagenesis or irradiation as well as various ways of tissue cultures.

The further development resulted in the presently most advanced methods of modern biotechnologies, the production of organism by genetic modification using introduction of defined new or recombinant genetic material by vectors and transformation methods. These organisms are typically named Genetically Modified organisms or GM organisms.

Improved methodology for the development of GM organisms GMOs by homologous recombination may ultimately reduce the potential for unintended effects, including health effects, of the inclusion of new genes randomly in the genome, stemming from present technology.

Likewise improved methods for a molecular containment of recombinant genes may reduce problems of unintended gene dispersal. Conflicting assessments and incomplete substantiation of the benefits, risks and limitations of GM food by various scientific, commercial, consumer and public organizations have resulted in national and international controversy regarding their safe use as food and safe release into the environment.

An example is the recent debate on food aid that contained GM material offered to countries in southern Africa in This international debate has often been focused on human health and environmental safety of these new products. At present, only a few food crops are permitted for food use and traded on the international food and feed markets. These include herbicide- and insect-resistant maize Bt maize , herbicide-resistant soybeans, rape canola oilseed and insect- and herbicide-resistant cotton primarily a fibre crop, though refined cottonseed oil is used as food.

In addition, several government authorities have approved varieties of papaya, potato, rice, squash, sugar beet and tomato for food use and environmental release. Further development of GM crops is likely to produce a range of GM crops with enhanced nutritional profiles.

A significant proportion of these traits relates directly to human health, the beta-carotene Vitamin-A precursor rich "golden rice" as the most well-known example. Other examples with health implications are removing allergens and anti-nutrients, altering fatty-acid profiles and increasing the anti-oxidant content. All new products related to such potential health benefits will naturally need to be scrutinized through thorough environmental and food safety risk assessments.

An analysis of risks and effects of food production practices using modern methods of biotechnology needs to reflect on all developments in the area, based on knowledge of modern biology and keeping in mind that the definition of modern biotechnology is often not very standardized. Integrated pest management IPM needs to be seen in the light of modern biotechnology because of the use of advanced bio-technological methods: Definitions of IPM cover a range of approaches: Suitable pest control methods should be used in an integrated manner and pesticides should be used on an "as needed basis" only, and as a last resort component of an IPM strategy.

In such a strategy, the effects of pesticides on human health, the environment, sustainability of the agricultural system and the economy should be carefully considered. According to FAO, IPM programmes are designed to generate independence and increased profits for farmers, and savings on foreign imports for governments.

IPM enables farmers to make informed decisions to manage their crops. Sometimes also organic farming is discussed as a modern technology for food production, where farmers adhering to this idea are aiming for similar objectives like IPM but more clearly pronounce the ideas of integrity, self determination and co evolution.

Principles of the environmental risk assessment, ERA: In many national regulations the elements of the ERA for GM food organisms include the biological and molecular characterizations of the genetic insert, the nature and environmental context of the recipient organism, the significance of new traits of the GMO for the environment, and information on the geographical and ecological characteristics of the environment in which the introduction will take place.

The risk assessment focuses especially on potential consequences on the stability and diversity of ecosystems, including putative invasiveness, vertical or horizontal gene flow, other ecological impacts, effects on biodiversity and the impact of presence of GM material in other products. Internationally the concept of familiarity was developed also in the concept of environmental safety of transgenic plants. Familiarity can also be used to indicate appropriate management practices including whether standard agricultural practices are adequate or whether other management practices are needed to manage the risk OECD, Currently the Cartagena Protocol on Biosafety to the Convention on Biological Diversity is the only international regulatory instrument which deals specifically with the potential adverse effects of genetically modified organisms known as Living Modified Organisms LMOs under the Protocol on the environment.

The Biosafety Protocol covers transboundary movements of any genetically modified foods that meet the definition of LMO. The Protocol establishes a harmonized set of international rules and procedures designed to ensure that countries are provided with the relevant information, through the information exchange system called "Biosafety Clearing-House". This Internet-based information system enables countries to make informed decisions before agreeing to the import of LMOs.

It also ensures that LMO shipments are accompanied by appropriate identification documentation. Furthermore, the scope of its consideration of human health issues is limited, given that its primary focus is biodiversity, in line with the scope of the Convention itself. Potential unintended effects of GMOs on non target organisms, ecosystems and Biodiversity: Potential risks for the environment include unintended effects on non target organisms, ecosystems and biodiversity.

Insect resistant GM crops have been developed by expression of a variety of insecticidal toxins from the bacterium Bacillus thuringiensis Bt. Detrimental effect on beneficial insects or a faster induction of resistant insects depending on the specific characteristics of the Bt proteins, expression in pollen and areas of cultivation have been considered in the environmental risk assessment ERA of a number of insect protected GM crops.

These questions are considered an issue for monitoring strategies and improved pest resistance management, which inherently can affect food safety in the longer term.

Under certain agro-ecological situations, such as a high weed pressure, the use of herbicide tolerant crops has resulted in a reduction in quantity of the herbicides used, in other cases no herbicide reductions or even the need of increased herbicide uses have been reported. Out-crossing of transgenes has been reported from fields of commercially grown GM plants including oilseed rape and sugar beet, and has been demonstrated in experimental releases for a number of crops including rice and maize.

Out-crossing could result in an undesired transfer of genes such as herbicide resistance genes to non-target crops or weeds creating new weed management problems. The consequences of out-crossing can be expected in regions where a GM crop has a sympatric distribution and synchronized flowering period, that is highly compatible with a weedy or wild relative species as demonstrated e.

The possibility that certain genetically engineered fish and other animals may escape, reproduce in the natural environment and introduce recombinant genes into wild populations is a concern of a report of a recent US Academy of Science study [46]. Genetically engineered insects, shellfish, fish and other animals that can easily escape, are highly mobile and form feral populations easily, are of concern, especially if they are more successful at reproduction than their natural counterparts.

For example, it is possible that transgenic salmon with genes engineered to accelerate growth released into the natural environment could compete more successfully for food and mates than wild salmon, thus endangering wild populations. The use of sterile all-female genetically engineered fish could reduce interbreeding between native populations and farmed populations, a current problem with the use of non-engineered fish in ocean net-pen farming.

Sterility eliminates the potential for spread of transgenes in the environment, but does not eliminate all potential for ecological harm. Monosex triploidy is the best existing method for sterilizing fish and shellfish, although robust triploidy verification procedures are essential.

Gene transfer between bacteria belonging to different species, genera or even families has been demonstrated in soil and other systems. Such gene transfer goes on between ordinary microorganisms in all ecosystems, and has also been demonstrated from GM microorganisms to other microorganisms, e.

The transfer of antibiotic genes to microorganisms present in foods and of clinical importance is an unwanted event relative to food safety, while the very low frequency of such transfer most probably leads to very low levels of concern. Only a limited number of releases of GM microorganisms e.

Pseudomonas and Rhizobia have been permitted mainly to explore the spread and the fate of microorganisms in nature. In some cases released GM bacterial populations have been found to persist in the soil for years. Regional specificity in safety assessments: Contradictory findings as relates benefits or disadvantages for the same GM crop may reflect different agro-ecological conditions in different regions. For example, the use of herbicide resistant crops and the consequent herbicide use could potentially be detrimental in a small sized agricultural area, which has extensive crop rotation and low levels of pest pressure.

However, the moderate herbicide use related to these GM plants could be beneficial in other agricultural situations where it might represent a decrease in herbicide use. Presently, no conclusive evidence on environmental advantages or costs can be generalized from the use of GM crops.

Consequences may vary significantly between different GM traits, crop types and different local conditions including ecological and agro-ecological characteristics. In , the UK government asked an independent consortium of researchers to investigate how growing genetically modified GM crops might affect the abundance and diversity of farmland wildlife compared with growing conventional varieties of the same crops.

The researchers stress that the differences they found do not arise just because the crops have been genetically modified. They arise because these GM crops give farmers new options for weed control where they use different herbicides and apply them differently.

Monitoring of human health and environmental safety: In the future specific GM organisms may gain approvals for widespread production where the approval may not always include the possibility to enter them also in the human food supply. Examples could be plants or animals used for drug production. In such situations, it will be important to consider whether or not to apply post-market monitoring for unexpected environmental spread of the GM animals or animals and their transgenes in the event that these would pose food safety hazards.

A prerequisite for any kind of monitoring are tools to identity or trace GMOs or products derived from GMOs in the environment or food-chain. Detection techniques such as PCR are in place in a number of countries to monitor the presence of GMOs in foodstuffs, to enable the enforcement of GM labelling requirements and for the monitoring of effects on the environment. Attempts to standardize analytical methods for tracing GMOs have been initiated e.

The need to assess indirect effects of the use of GMOs in food production has been emphasized by many countries. For example, the production of chemicals or enzymes from contained GM micro-organisms e. A further example of beneficial human environmental outcomes of the use of GM crops is the reduction in the use, environmental contamination and human exposure to pesticides demonstrated in some areas. This has been demonstrated especially through the use of pesticide resistant Bt cotton, which has been shown to decrease pesticide poisoning in farm workers [51].

Out-crossing of GM plants with conventional crops or wild relatives, as well as the contamination of conventional crops with GM material, can have an indirect effect on food safety and food security by contamination of genetic resources [52]. The Codex guidelines for the safety assessment of GM foods include the analysis of potential unintended effects, where effects on the environment may result in unintended, indirect effects on human health.

Crop breeding strategies are highly dependent upon preservation of diversity of crops and wild relatives. Many methods of conventional and modern biotechnology can interfere with diversity of organisms which have relevance for further breeding. In crops these methods can often concentrate on the further improvement of few elite lines only. The majority of locally adapted land races e. Also the system for the protection of intellectual property rights interferes with crop diversity.

There is growing scientific and public concern about a rapid decline of diversity, e. On the other hand modern methods of biotechnology can be beneficial for enabling diversity in scenarios where possibilities of conventional breeding are difficult because of sterility and pests, e.

Historically, plant genetic resources were freely provided by developing countries to gene-banks world-wide. Now international policy attaches importance to national ownership of such resources. An important aspect for the future potential of agricultural research is access to genetic resources for researchers on terms that recognize the contributions made by farmers to the conservation and sustainable utilization of these resources.

The International Treaty on Plant Genetic Resources adopted at a conference by the Food and Agriculture Organization in November , provides the legal framework for dealing with the resources on which food security and sustainable agriculture depend.

The Treaty gives a directive on the conservation and sustainable use of plant genetic resources for food and agriculture making provision for the fair and equitable sharing of the benefits arising out of their use, in harmony with the United Nations Convention on Biological Diversity CBD.

The Treaty also addresses farmers' rights. The Treaty establishes a Multilateral System of Facilitated Access and Benefit-sharing MLS for key crops, emphasizing the interdependency of countries in terms of plant genetic resources for food and agriculture.

The developing countries rich in genetic resources are encouraged to place germplasm in the MLS. The users of the material will sign a Material Transfer Agreement, incorporating the conditions for access and benefit sharing through a fund established under the Treaty.

In return, the owners of the genetic resources would get a share of the benefits arising from their use and development in the way of information, technology transfer and capacity building. Agency for International Development reported that between and the year the world lost 22 percent of its high-potential agricultural land.

That's , square miles, an area equal in size to Alaska. The loss is alarming because, as population pressures mount, agricultural production will have to expand onto medium- and low-potential lands that are not only less productive but also more fragile and susceptible to degradation.

Soil is degraded mainly through deforestation, agricultural activities, overgrazing, and overexploitation. Biophysical manifestations include erosion and loss of moisture-holding capacity. But more important, and more complex, are the social and economic aspects. Indeed, some view land degradation as a socioeconomic rather than biophysical problem. For example, population growth increases demand for land on which to grow crops, which often leads to deforestation, shorter fallow periods, and continuous cropping.

Short-sighted economic policies often make the problem worse by encouraging farmers to clear new land for cultivation rather than to protect land already under cultivation. Insecure land tenure arrangements discourage farmers from making long-term investments needed for resource conservation. The Impacts of trade liberalization: The implementation or reform of agricultural and trade policy creates a complicated set of environmental effects - some negative, some positive, and in some cases linked to food safety issues.

The effect of freer agricultural trade on environmental quality depends on a number of factors, such as the mix of post-reform commodities, level of output, changes in production inputs, land use, technical change, and the capacity of the natural resource base to assimilate production impacts. The additional effect of such changes related to food safety will in many cases relate to the existence of food safety systems and experience related to the new or increase food commodity production.

Freer trade improves market access for goods previously governed by quantity restrictions such as quotas and other non-tariff barriers and aligns domestic prices closer to world prices. Resource reallocation occurs as prices adjust to market conditions and reflect the availability of resources such as arable land, labour, and other farming inputs. As prices change, farmers respond by altering their crop mix and their input use, buying or selling land, and investing in new machinery.

In addition, trade and health considerations are intimately connected. The use of international standards for traded food, focusing on food safety, but in the future also most likely on environmental issues, will have the potential to improve not only internationally traded food but also local food, and thereby the health of local consumers. This in turn would then favour both health and social and economic development - a true win-win situation. This Facility will hopefully provide the means for developing countries to strengthen their systems to comply with international standards to the benefit of both exported and locally consumed food.

International agreements related to nature and food production are summarized in a report from FAO on ethical issues in food and agriculture. They include the value of food, the value of enhanced well-being, the value of human health, the value of natural resources, and the value of nature, whereas the Convention on Biological Diversity recognizes that nature itself is to be valued for what it is. Explore the development of an EoE management plan.

Attend this educational webinar to learn about the first and only hypoallergenic formula with prebiotics and probiotics: In this webinar, you will also review the extensive clinical trials platform behind this exciting innovation, as well as practical information and available tools for this new formula. To review medical and scientific rationale for the addition of prebiotics and probiotics to hypoallergenic infant formula.

To share the main results of the 3 clinical trials behind Neocate Syneo Infant. To discuss the unique blend of prebiotics and probiotics in Neocate Syneo Infant.

To review the practical use of Neocate Syneo Infant and tools available to support patients on the product. Please join Kelly A. Her talk covers advances in the knowledge of the infant intestinal microbiome in health and disease.

This was part of a Satellite Symposium, Emerging Evidence: Discuss the development of the human gastrointestinal tract. Explain the optimal nutrition provided by human milk. Understand the impact of pre- and probiotics on intestinal health. A growing body of evidence highlights the importance of the gut microbiota in early life. Research shows that infants with cow milk allergy may have a gut dysbiosis. Please join speaker, Christina West, MD, PhD for a 1-hour educational webinar to explore the role of specific pre- and probiotics in addressing this gut dysbiosis.

To explore the role of the infant gut microbiota in health and allergic disease. To discuss the role of specific pre- and probiotics in addressing dysbiosis. The gut microbiota is an area of growing interest and clinical research. The gut microbiota is receiving increasing attention related to its relationship with immune disorders, including allergic conditions. Demonstrate that children may present with multi-system allergic disease. Show altered mechanisms of development of sensitization and tolerance.

Discuss clinical research investigating synbiotics in allergic conditions. Share a case study demonstrating co-occurrence of gastrointestinal and allergic symptoms. Cow milk allergy is one of the most confirmed food protein allergies in early childhood. Dietary management is vital in managing this condition. Understand the role of human milk in infants with cow milk allergy. Discuss role of maternal diet when managing cow milk allergy. Distinguish differences in composition and categorization of specialized pediatric formulas.

Understand the proper use of specialized pediatric formulas based on currently available evidence. Join Marijn Warners, MD, PhD-fellow, for a free educational webinar to discuss her new research on the effectiveness of an elemental diet in the management of adult patients with EoE.

Dietary treatment with elimination of disease triggering allergens is an effective treatment option since it could provide a long-term and drug-free solution. Elemental amino acid-based diets are highly effective in children, and this new research supports its use in successfully managing adult patients with EoE.

Evaluate the effect of an amino acid-based formula diet on eosinophilic inflammation, endoscopic signs and symptoms of adult EoE patients.

Describe the contribution of abnormal esophageal barrier function in the pathophysiology of EoE. Explain the role of an amino acid-based formula diet in restoring esophageal mucosal integrity and induces histologic remission in adult EoE patients. Explore the role of an impaired small intestinal mucosal integrity in the pathophysiology of EoE. Her current research focuses on understanding the pathophysiology of esophagel mucosal integrity in eosinophilic esophagitis, the effect of dietary treatment in EoE and the validation of different outpoints used in clinical trails in EoE.

Warners completed two consecutive internships in surgery and urology at The University Medical Center Groningen and St. Feeding problems are common in children with ASD and can result from a variety of reasons e.

In addition, they may present in a variety of ways — often disrupting eating and mealtimes. Define ASD diagnostic characteristics and how these relate to the mechanics of eating.

Discuss prevalent underlying medical problems such as gastrointestinal issues and food allergies that may contribute to disrupted eating patterns in children with ASD.

Dietary management of EoE has been shown to be an effective option for children and is gaining great acceptance for adults. To learn about the different types of elimination diets.

To become familiar with feeding issues that may develop as a result of EoE. To be able to provide patients and families with survival skills to help them be successful with their elimination diet. There is a general lack of awareness about FPIES, which has led to this condition being frequently misdiagnosed.

This is an ideal educational opportunity for those looking to enhance their knowledge and skills on FPIES management. At the conclusion of the webinar, participants should be able to: Nirmala Gonsalves and Bethany Doerfler for a Nutricia Learning Center educational webinar focused on transitioning teens with EoE from pediatric to adult care.

Describe the clinical features of EoE across the age spectrum and discuss the evidence for dietary management approaches. Explore transition of care in EoE from teens to adulthood. Understand the role enteral nutrition plays in the intestinal rehabilitation process. Discuss the ways diet modifications can reduce the complications of long-term TPN. Please join speaker Dr. Describe the most commonly occurring GI symptoms and potential nutritional deficits in children with ASD.

When, Which Approach, and Why? Please join speakers Dr. Lurie Children's Hospital of Chicago for a free one hour presentation on the dietary management of eosinophilic esophagitis. Define and describe the prevalence and clinical spectrum of eosinophilic esophagitis.

Describe the different dietary approaches to managing eosinophilic esophagitis. Understand the principles underlying elimination diets and the importance of avoiding cross-contamination. Recognize the varying disease processes that fall under the diagnosis of cow milk allergy. Appreciate nutritional risks associated with cow milk allergy. Understand the role of nutrition management in the care of a child with cow milk allergy.

Describe symptoms, prevalence and the most causative foods associated with gastrointestinal food allergy. Understand different aspects of an elimination diet including avoidance of causative foods, symptom management and nutritional adequacy. November 29, Please join Dr. Review the nutritional management of patients with short bowel syndrome. Learn about the possible nutritional deficiencies of an infant with short bowel syndrome.

Review the role enteral nutrition plays in the intestinal adaptation. Identify GI conditions that typically lead to compromised gut health in the neonate such as necrotizing enterocolitis and short bowel syndrome. Recognize key indicators of feeding success or intolerance, including manifestations of food allergies. Incorporate various nutritional strategies to help manage compromised gut health in the newborn. March 21, Please join Dr.

Stimulating intestinal function with prebiotics. Supporting oral feeding in malabsorptive patients. Identify specific characteristics of feeding issues in the young child and older child with EoE. Understand that medical treatment alone may not remediate symptoms of feeding dysfunction in children with EoE. Recognize criteria for referral to a feeding specialist. The seven key signs of acid reflux in a baby. Myths and misconceptions about the care and treatment of a baby with colic.

Join our speakers Laurie Bernstein and Fran Rohr in a discussion about the Simplified PKU Diet and how this approach could potentially increase diet adherence and enjoyment of a more normalized approach to food for patients with PKU.

By partaking in this webinar, participants will be able to: Understand the rationale for using the simplified diet. Teach the simplified PKU diet to their patients. Share best practices around this approach to PKU management. What Do We Know? Join us for a 1 hour educational webinar with Dr. At the end of this webinar, participants will be able to: Understand the relationship between plasma levels and brain uptake of essential amino acids. Understand how medical food composition affects brain amino acid nutrition and development in disorders of intermediary metabolism.

We recommend you transition your patient to a product within our portfolio that will work for your patients. Below are tools that can be found in the Clinician Resources, Metabolics section: Calculation tool to help determine the amount of Nutricia product needed to achieve a desired amount of protein equivalent for individual patients.

Nutricia Metabolic Portfolio Guide: The major goals of a cardiac rehabilitation program are:. Retard or reverse atherosclerosis by instituting programs for exercise training, education, counseling, and risk factor alteration. Reintegrate heart disease patients into successful functional status in their families and in society. Cardiac rehabilitation programs have been consistently shown to improve objective measures of exercise tolerance and psychosocial well being without increasing the risk of significant complications.

However, there is evidence that participation has increased. Current cardiac care has already reduced early acute coronary mortality so much so that further exercise training, as an "isolated" intervention, may not be able to cause significant reduction in the morbidity and mortality. Therefore, the outcome measures of cardiac rehabilitation now include improvement in quality of life QOL , such as the patient's perception of physical improvement, satisfaction with risk factor alteration, psychosocial adjustments in interpersonal roles, and potential for advancement at work commensurate with the patient's skills rather than simply return to work.

Similarly, among patients who are elderly, such outcome measures may include the achievement of functional independence, the prevention of premature disability, and a reduction in the need for custodial care. In addition, the safety of exercise within cardiac rehabilitation programs, as studied in over 4, patients, is well accepted and established.

Cardiac rehabilitation services are, therefore, an effective and safe intervention. These services are undoubtedly an essential component of the contemporary treatment of patients with multiple presentations of coronary heart disease and heart failure. Angina Pectoris in Emergency Medicine. Complications of Myocardial Infarction.

Myocardial Infarction Emergency Medicine. Myocardial Infarction in Childhood. Vascular Diseases and Rehabilitation. Resource Center Heart and Lung Transplant. In the s, patients with myocardial infarction MI were advised to observe 6 weeks of bedrest. Chair therapy was introduced in the s, and by the early s, minutes of daily walking was advocated, beginning at 4 weeks.

Clinicians gradually began to recognize that early ambulation avoided many of the complications of bed rest, including pulmonary embolism PE , and that it did not increase the risk. However, concerns about the safety of unsupervised exercise remained strong; this led to the development of structured, physician-supervised rehabilitation programs, which included clinical supervision, as well as electrocardiographic monitoring.

In the s, Hellerstein presented his methodology for the comprehensive rehabilitation of patients recovering from an acute cardiac event. His approach was adopted by cardiac rehabilitation programs throughout the world. Despite multiple advances, Hellerstein's original ideas have not been improved upon significantly. However, due to changing patient demographics, many more patients now have the opportunity to receive the benefits offered by cardiac rehabilitation. Multifactorial intervention, including aggressive risk factor modification, has become an integral part of present day cardiac rehabilitation.

Cardiac rehabilitation has to be comprehensive and, at the same time, individualized. The main goals of a cardiac rehabilitation program are noted below. Decreasing the risk of sudden cardiac arrest or reinfarction [ 10 , 11 ]. Coronary vasodilatation is mainly driven by the bioavailability of nitric oxide NO , which is produced by the activities of the endothelially derived enzyme NO synthase and is metabolized by reactive oxygen species.

This fine-tuned balance is disturbed in people with CAD. This form of impairment of NO production, along with excessive oxidative stress, results in the loss of endothelial cells via apoptosis.

Further aggravation of endothelial dysfunction ensues, which triggers myocardial ischemia in persons with coronary artery disease CAD. In healthy individuals, an increased release of NO from the vascular endothelium in response to exercise training results from changes in endothelial NO synthase expression, phosphorylation, and conformation. By the same token, exercise training has assumed a role in the cardiac rehabilitation of patients with CAD, because it reduces mortality and increases myocardial perfusion.

This has been largely attributed to the exercise training—mediated correction of coronary endothelial dysfunction in persons with CAD. In persons with CAD, regular physical activity leads to a restoration of the balance between NO production by NO synthase and NO inactivation by reactive oxygen species, thereby enhancing the vasodilatory capacity in various vascular beds.

Because endothelial dysfunction has been identified as a predictor of cardiovascular events, the partial reversal of endothelial dysfunction achieved by regular physical exercise appears to be the most likely mechanism behind the exercise training—induced reduction in cardiovascular morbidity and mortality in patients with CAD. The amount of exercise in the year before cardiac surgery has been linked to the incidence of postoperative atrial fibrillation during rehabilitation according to a study by Giaccardi et al.

The incidence of atrial fibrillation during rehabilitation was significantly higher in patients who performed low-intensity physical exercise the year before surgery compared with those who performed moderate-intensity exercise. The occurrence of atrial fibrillation during the patients' hospital stay, a larger left atrial volume, and a lower left atrial emptying fraction were independent predictors of atrial fibrillation during rehabilitation. Cardiac rehabilitation programs include walking as part of the exercise regimen.

Patients were asked to rate the change in their walking ability between these two tests. Physiotherapists, who supervised the training, also gave their input. The minimal clinically important difference and mean change in the 6-minute walk test distance was 25 m; no difference was found in the meter fast walk test.

These results should help physicians interpret the changes made by their patients in a clinical context and also be used in further studies that use 6 MWD as a measure. A study by Bellet et al indicated that cardiac rehabilitation patients may derive the same benefit from a program of once-weekly supervised exercise sessions as they do from a program of twice-weekly sessions.

The study found that improvements in the 6-minute walk test distance were the same after 6 weeks of low to moderate intensity training in the once-weekly exercise group patients as in the twice-weekly group patients. A study by El Demerdash et al indicated that in patients with ischemic heart disease who are not suitable for cardiac revascularization procedures, a cardiac rehabilitation program can reduce ischemic burden.

In the study, 40 patients with ischemic heart disease who were unsuitable for percutaneous coronary intervention or coronary artery bypass grafting participated in a program that included twice-weekly, low-intensity exercise, as well as patient education, smoking cessation, and nutritional, medical, psychological, and sexual counseling. Cardiac rehabilitation encompasses short-term and long-term goals that are to be achieved through exercise, education, and counseling.

Patients generally fall into following categories:. Patients with chronic, stable angina pectoris. Patients who have undergone heart transplantation. Patients who have not had prior events but who are at risk because of a remarkably unfavorable risk factor profile.

Patients with previously stable heart disease who have become seriously deconditioned by intercurrent, comorbid illnesses. The cardiac rehabilitation programs benefit women and men equally. The risk stratification process is very valuable for cardiac patients; it serves as the basis for individualizing the prescription of exercise training and for assessing the need and extent of supervision required.

The risk stratification process is based on the assessment of the patient's functional capacity, on the patient's educational and psychosocial status, on whether alternatives to traditional cardiac rehabilitation can be used, and on whether the patient is suffering from myocardial ischemia, ventricular dysfunction, or arrhythmias.

The term functional capacity refers to the maximum ability of the heart and lungs to deliver oxygen and the ability of the muscles to extract it. Functional capacity is measured by determining the maximal oxygen uptake VO 2 max during incremental exercise.

In most patients, a rough calculation of functional capacity can be performed by using multiples of 1 MET metabolic equivalent, 3. In complicated patients, such as those with severe left ventricular LV dysfunction and congestive heart failure CHF , the functional capacity can be ascertained with greater accuracy by using cardiopulmonary exercise CPX testing.

Most cardiac rehabilitation facilities, however, are not currently equipped for CPX. Skeletal muscle performance, such as deconditioning or in the presence of concurrent, noncardiac illness. Every attempt should be made to recognize the potential effects of these factors on functional capacity in order to minimize risk of the individualized reconditioning program that is being formulated. Symptomatic or asymptomatic silent myocardial ischemia may limit the patient's exertional capacity by causing limiting angina, dyspnea, or fatigue.

Fixed LV dysfunction or damage may be present in the absence of angina. Patients with LV dysfunction develop early dyspnea and easily become fatigued. Cardiopulmonary exercise testing preferably should be performed to determine the functional capacity in an objective manner. Exercise intolerance in patients with LV dysfunction is due to skeletal muscle hypoperfusion resulting from inadequate cardiac output that can be better quantified by measuring VO 2 max.

Ventricular irritability and complex ventricular arrhythmias require assessment through the use of signal-averaged electrocardiogram ECG or electrophysiologic studies.

Appropriate medical or device treatments should be undertaken whenever feasible prior to beginning phase 2 of the cardiac rehabilitation program. Very close surveillance is necessary in patients with significant cardiac arrhythmias during their exercise training routines. Concomitant rhythm monitoring with telemetry, Holter or event monitoring should be considered.

In many cases of serious arrhythmias, therapy remains controversial and the safety of is exercise unclear; such uncertainties complicate the decision-making process. Patients with severe ventricular arrhythmias and uncontrolled supraventricular arrhythmias should be excluded from exercise training unless proper evaluation and effective therapy has been instituted. Patients with devices, such as pacemakers and defibrillators, should be carefully monitored during exercise.

Rate-responsive pacemakers are quite helpful even for those patients who are completely pacemaker-dependent. In case of implantable cardioverter defibrillators ICDs , exercise training can be provided as long as underlying arrhythmias are controlled with pharmacotherapy.

Heart rate should be kept well below the threshold at which the antitachycardia algorithm of the ICD begins. Exercise does provide some benefit, but severe cases may require specific therapy that has been shown to enhance the benefits derived from subsequent cardiac rehabilitation. The promotion of self-efficacy and control over one's activities is of paramount importance for boosting self-confidence. Coronary-prone behavior CPB is known as a cardiac risk factor, but its effect on prognosis is unclear.

Some data suggest that the modification of CPB can improve the coronary disease prognosis. Initially, continuous ECG monitoring is recommended for most patients during cardiac rehabilitation exercise training; however, clinicians may decide whether to use continuous or intermittent ECG monitoring.

After the initial period, the use of electrocardiography depends on the clinical judgment of the supervising physician. In carefully selected patients, alternatives to the traditional supervised group or individual cardiac rehabilitation program have been examined.

These alternatives, which are applicable primarily to very low-risk patients, include the following options:.

Heart rate recovery HRR following maximal exercise has been found to be a predictor of all-cause mortality. In a study, Streuber and colleagues hypothesized that aerobic exercise training could improve HRR in patients who have suffered heart failure, because athletes are known to have accelerated HRR, while cardiac rehabilitation has been shown to positively effect such recovery in patients with coronary artery disease CAD. The results indicated that in patients with heart failure who have low exercise capacity, even short-term aerobic training can aid HRR.

Cardiac rehabilitation initially was designed for low-risk cardiac patients. Now that the efficacy and safety of exercise have been documented in patients previously stratified to the high-risk category, such as those with congestive heart failure CHF , the indications have been expanded to include such patients.

In such patients, every effort should be made to correct these abnormalities through optimization of medical therapy, revascularization by angioplasty or bypass surgery, or electrophysiologic testing and subsequent antiarrhythmic drug or device therapy. Patients should then undergo retesting for exercise prescription. Two forms of exercise tests are performed in patients following an acute cardiac event: Furthermore, CPX also may be performed, particularly in patients with cardiomyopathy or CHF, to determine objectively the patient's exercise capacity.

A representative schedule might begin exercise at intervals, such as days following uncomplicated acute myocardial infarction MI , days following angioplasty, or days after bypass surgery. Submaximal exercise testing is not necessarily safer than symptom-limited testing. In fact, the submaximal strategy may have certain disadvantages; it can lead to inappropriate limitation in the patient's routine activities and exercise training and to a significant delay in the patient's return to work.

The use of submaximal exercise may also result in a failure to elicit important factors in prognosis, such as ischemia, cardiac dysfunction, and arrhythmia. Incremental exercise is employed, using modified Naughton protocol for treadmill or modified protocols on a bicycle ergometer.

Concomitant minute-to-minute breath analysis and measurement of oxygen consumption and elimination of carbon dioxide are performed to determine VO 2 max, which is the most objective method of determining functional capacity in patients with cardiac dysfunction, valvular disease, or recent acute cardiac event.

Modified Bruce or Naughton protocols typically are used during the testing phase, because the standard Bruce protocol has been modified to avoid too abrupt an increase in METs by METs per stage.

The modified Naughton protocol starts at a lower MET workload and increases by 1 MET per stage, thus allowing better-tolerated gradual progression in exercise and a more accurate assessment of exertional capacity. Severe abnormalities found on stress testing may contraindicate exercise training until they have been corrected. Less severe abnormalities, such as the development of the above symptoms at high workloads, may not necessarily contraindicate exercise training; however, certain modifications and closer surveillance may be required, including ECG monitoring.

Some reports have questioned early exercise training following acute anterior MI, suggesting that it may lead to abnormal scar formation. Nonetheless, evidence is strong that moderate exercise training is not associated with worsening LV function in patients following acute anterior MI. Phase 2 of a cardiac rehabilitation program is initiated based on the result of the exercise testing, and the exercise prescription is individualized. Three main components of an exercise training program are listed below.

Patients usually need to allow minutes for each session, which includes a warm-up of at least 10 minutes. The intensity prescribed is in relation to one's target heart rate.